[Urolift®, a new minimally invasive treatment for patients with low urinary tract symptoms secondary to BPH. Preliminary results]. / Urolift®, un nuevo tratamiento mínimamente invasivo para los síntomas de tracto urinario inferior secundarios a HBP. Resultados preliminares.

OBJECTIVES: To report the preliminary results of one of the first series of patients treated with a new simple surgical technique for the treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) and to evaluate its safety and feasibility. METHODS: We have performed a novel surgical treatment of BPH, the UroLift® System (Neotract, Inc). It opens the urethra directly by retracting the obstructing prostatic lobes without applying incisions, surgical resection or thermal injury to the prostate. RESULTS: The procedure was carried out in 20 patients with a mean age of 74.3 (43 hyphen;-90) years, with mean prostate volume of 42.6 mL (19 hyphen;109) using the same operative protocol in all case subjects. Mean operative time was 19.1 min (range: 12-45). International Prostate Symptom Score (IPSS) ) at 4 weeks reduced from 26.7 to 16.7 and peak urinary flow rate (Qmax) increased from 8.6 mL/s to 13.2 mL/s. No major complications were encountered, neither sexual dysfunction. Mean follow-up: 12.3 (2-22) months. CONCLUSIONS: The UroLift® System procedure appears to be safe and efficient at short term. This technique minimizes the bleeding of the urethra and, therefore, makes bladder catheter not always necessary, and can preserve sexual function with low morbidity. Further studies are warranted to determine long-term outcome.

Urolift®, un nuevo tratamiento mínimamente invasivo para los síntomas de tracto urinario inferior secundarios a HBP. Resultados preliminares / Urolift®, a new minimally invasive treatment for patients with low urinary tract symptoms secondary to BPH. Preliminary results

OBJETIVO: Presentar una de las primeras series de pacientes tratados con una nueva y sencilla técnica quirúrgica para los síntomas del tracto urinario inferior secundaria a HBP, evaluando su seguridad y eficacia con resultados preliminares. MÉTODOS: Se ha empleado una nueva técnica para el tratamiento quirúrgico de la HBP, el UroLift® System (Neotract, Inc.), que aumenta el calibre de la uretra prostática de forma directa, retrayendo los lóbulos prostáticos obstructivos sin realizar incisiones, resección quirúrgica o daño térmico sobre el tejido prostático. RESULTADOS: El procedimiento ha sido realizado sobre 20 pacientes (media edad: 74.3 años) con un volumen medio prostático de 42.6 cc. (19-109) y empleando el mismo protocolo en todos los casos. El tiempo medio de la intervención fue 19.1 min (7-45). La puntuación del International Prostate Symptom Score (IPSS) a las 4 semanas se redujo de 26.7 a 16.7 y el Flujo máximo (Qmax) se incrementó desde 8.6 mL/s hasta 13.2 mL/s. No se presentaron complicaciones mayores, ni afectación de la función sexual. Seguimiento medio: 12.3 (2-22) meses. CONCLUSIONES: El dispositivo UroLift® parece eficaz y seguro a corto plazo. Está nueva técnica minimiza el sangrado de la uretra prostática y, por tanto, no hace siempre necesario el empleo de sondaje vesical posterior. Además presenta una baja morbilidad, preservando la función sexual. Sin embargo debemos esperar los resultados de un número mayor de pacientes tratados mediante esta nueva técnica y con seguimientos más prolongados para extraer conclusiones más firmes (AU)

OBJECTIVES: To report the preliminary results of one of the first series of patients treated with a new simple surgical technique for the treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) and to evaluate its safety and feasibility. METHODS: We have performed a novel surgical treatment of BPH, the UroLift® System (Neotract, Inc). It opens the urethra directly by retracting the obstructing prostatic lobes without applying incisions, surgical resection or thermal injury to the prostate. RESULTS:The procedure was carried out in 20 patients with a mean age of 74.3 (43-90) years, with mean prostate volume of 42.6 mL (19-109) using the same operative protocol in all case subjects. Mean operative time was 19.1 min (range: 12-45). International Prostate Symptom Score (IPSS) at 4 weeks reduced from 26.7 to 16.7 and peak urinary flow rate (Qmax) increased from 8.6 mL/s to 13.2 mL/s. No major complications were encountered, neither sexual dysfunction. Mean follow-up: 12.3 (2-22) months. CONCLUSIONS: The UroLift® System procedure appears to be safe and efficient at short term. This technique minimizes the bleeding of the urethra and, therefore, makes bladder catheter not always necessary, and can preserve sexual function with low morbidity. Further studies are warranted to determine long-term outcome (AU)

Endoscopic treatment of a giant fibroepithelial polyp of the ureter.

SUMMARY OBJECTIVES: Fibroepithelial polyps are benign mesenchymal tumors with a morphology and clinical presentation very similar to transitional cell carcinomas, so that differential diagnosis is of paramount importance. METHODS/RESULTS: We present the case of a 42-year-old female patient, with history of mediastinal Hodgkin/s lymphoma, which came to the office reporting right low back colic pain and haematuria. CT scan showed pediculated neoformation of about 10 cm protruding into the bladder, with negative urine cytology. In view of the findings, and with the suspicion of fibroepithelial polyp, an endoscopic exploration was performed, confirming the diagnosis, followed by exeresis with Holmium laser. DISCUSSION: A differential diagnosis between fibroepithelial polyp and transitional cell carcinoma cannot be made with imaging tests alone. The suspicion must be established, and endoscopic exploration indicated, by means of ureterorenoscopy or percutaneous nephroureteroscopy, whatever is a better indication, with biopsy or definitive endoscopic treatment of the tumor. CONCLUSIONS: Endoscopic exploration is currently the procedure of choice for the diagnostic confirmation of this condition and its definitive treatment.

Tratamiento endoscópico de un pólipo fibro-epitelial gigante de uréter / Endoscopic treatment of a giant fibroepithelial polyp of the ureter

OBJETIVOS: Los pólipos fibroepiteliales son tumores mesenquimales de carácter benigno, con una morfología y presentación clínica muy similar a los carcinomas uroteliales, por lo que resulta de gran importancia su diagnóstico diferencial.METODOS/RESULTADOS: Presentamos el caso de una paciente de 42 años, con antecedentes de Linfoma Hodking mediastínico, que acude a consulta por dolor cólico lumbar derecho y hematuria. En TAC se objetiva neoformación pediculada de unos 10cm que protruye en vejiga con citología de orina negativa. Ante los hallazgos, y con la sospecha de pólipo fibroepitelial, se decide exploración endoscópica, que confirma el diagnóstico, y se procede a su exéresis con láser de Holmium.DISCUSIÓN: El diagnóstico diferencial entre pólipo fibroepitelial y carcinoma urotelial no es posible realizarlo únicamente con pruebas de imagen. Se debe establecer la sospecha e indicar una exploración endoscópica, mediante ureterorrenoscopia o nefroureteroscopia percutánea según resulte más indicado, y la toma de biopsia o el tratamiento endoscópico definitivo de la tumoración.CONCLUSIONES: La exploración endoscópica es el procedimiento de elección actualmente tanto para la confirmación diagnóstica de esta patología, como para su tratamiento definitivo (AU)

OBJETIVES: Fibroepithelial polyps are benign mesenchymal tumors with a morphology and clinical presentation very similar to transitional cell carcinomas, so that differential diagnosis is of paramount importance.METHODS/RESULTS: We present the case of a 42-year-old female patient, with history of mediastinal Hodgkin’s lymphoma, which came to the office reporting right low back colic pain and haematuria. CT scan showed pediculated neoformation of about 10 cm protruding into the bladder, with negative urine cytology. In view of the findings, and with the suspicion of fibroepithelial polyp, an endoscopic exploration was performed, confirming the diagnosis, followed by exeresis with Holmium laser.DISCUSSION: A differential diagnosis between fibroepithelial polyp and transitional cell carcinoma cannot be made with imaging tests alone. The suspicion must be established, and endoscopic exploration indicated, by means of ureterorenoscopy or percutaneous nephroureteroscopy, whatever is a better indication, with biopsy or definitive endoscopic treatment of the tumor.CONCLUSIONS: Endoscopic exploration is currently the procedure of choice for the diagnostic confirmation of this condition and its definitive treatment (AU)

[Prognostic significance of the microscopic invasion of the renal vein wall in renal cell cancer]. / Valor pronóstico de la afectación microscópica de la vena renal en el cáncer de células renales.

OBJECTIVES: International TNM Staging System for renal cell carcinoma (RCC) classifies as T3b when "tumor grossly extends into the renal vein or its segmental branches, or vena cava below the diaphragm". The finding of microscopic invasion of the vein wall is not taken into account for TNM staging. We analyse its prognostic significance in localized and locally advanced RCC. METHODS: From January 1989 to July 2002, 257 RCC were surgically excised. Excluding Von Hippel-Lindau patients and stage IV (TNM 2002), 241 cases were studied in retrospect, with a median follow up of 50.96 months. Histopathological data from the renal vein were available in 216 specimens. There was renal vein wall invasion in 22. We compare the outcomes in this group vs. the group without microscopic involvement of the renal vein wall (n: 194). RESULTS: Mean age for the group with renal vein invasion (RVI) was 65.02 years. Mean tumour size in the same group was 9 cm, larger than in control group (p<0,001). Thrombus was found in 72.7% vs. 6.2% in the control group. Clear cell carcinoma (77.3%) was the predominant histological subtype. Nuclear grade 2 according to Fuhrman's Classification System accounts for 42.9% of the cases. Metastatic progression risk (HR: 4,86) and death risk (HR: 6,49) are significantly higher in RVI group. When renal vein thrombosis is found, progression and death risks are still higher (HR: 7.22 and 8.38, respectively). CONCLUSIONS: Microscopic invasion of the renal vein wall is a dependent prognostic factor for disease progression and death for RCC. Macroscopic renal vein involvement is an independent prognostic factor. When both factors are found together, disease outcome is worse.

Valor pronostico de la afectación microscópica de la vena renal en el cáncer de células renales / Prognostic significance of the microscopic invasion of the renal vein wall in renal cell cancer

OBJETIVO: En el carcinoma de células renales, la TNM define el estadio T3b como afectación macroscópica de la vena renal o cava infradiafragmática. El valor pronóstico de la invasión microscópica de la pared de la vena no se contempla. Analizamos la repercusión de ésta en la evolución de estos tumores, en estadios localizados y localmente avanzados.MÉTODOS: De 257 carcinomas de células renales operados (Enero de 1989 / Julio de 2002), se analizan retrospectivamente 241 (excluímos los estadios IV y los casos con enfermedad de Von-Hippel-Lindau). El seguimiento mediano es de 50,96 meses. Tenemos datos de la histología de la vena en 216 casos. Comparamos el grupo con invasión microscópica de la pared (22 casos) frente al resto (n: 194).RESULTADO: En el grupo con afectación de la pared, la edad media es 65,02 años. El tamaño medio es 9 cm (significativamente superior, p< 0,001). El 72,7% presentan trombo frente al 6,2% del segundo grupo. El 77,3% corresponden a tumores de células claras. El 42,9% tienen un grado 2 de Fuhrman. El riesgo de desarrollar metástasis (HR: 4,86) y de éxitus (HR: 6,49) es significativamente superior en el grupo con afectación de la pared. Este riesgo es superior ante la presencia de trombo (HR: 7,22 y HR: 8,38, respectivamente).CONCLUSIONES: La afectación microscópica de la pared de la vena renal actúa como factor pronóstico dependiente para la supervivencia y para la progresión. La afectación macroscópica de la vena actúa como factor pronóstico independiente, aunque los pacientes que presentan ambas circunstancias (afectación macro y microscópica) son los que presentan peor evolución(AU)

OBJECTIVES: International TNM Staging System for renal cell carcinoma (RCC) classifies as T3b when “tumor grossly extends into the renal vein or its segmental branches, or vena cava below the diaphragm”. The finding of microscopic invasion of the vein wall is not taken into account for TNM staging. We analyse its prognostic significance in localized and locally advanced RCC. METHODS: From January 1989 to July 2002, 257 RCC were surgically excised. Excluding Von Hippel-Lindau patients and stage IV (TNM 2002), 241 cases were studied in retrospect, with a median follow up of 50.96 months. Histopathological data from the renal vein were available in 216 specimens. There was renal vein wall invasion in 22. We compare the outcomes in this group vs. the group without microscopic involvement of the renal vein wall (n: 194).RESULTS: Mean age for the group with renal vein invasion (RVI) was 65.02 years. Mean tumour size in the same group was 9 cm, larger than in control group (p<0,001). Thrombus was found in 72.7% vs. 6.2% in the control group. Clear cell carcinoma (77.3%) was the predominant histological subtype. Nuclear grade 2 according to Fuhrman’s Classification System accounts for 42.9% of the cases. Metastatic progression risk (HR: 4,86) and death risk (HR: 6,49) are significantly higher in RVI group. When renal vein thrombosis is found, progression and death risks are still higher (HR: 7.22 and 8.38, respectively).CONCLUSIONS: Microscopic invasion of the renal vein wall is a dependent prognostic factor for disease progression and death for RCC. Macroscopic renal vein involvement is an independent prognostic factor. When both factors are found together, disease outcome is worse(AU)

[Atypical lymphatic dissemination of a testicular tumor from a cryptorquid testicle]. / Diseminación linfática atípica de un tumor testicular sobre un testículo criptorquídico.

OBJECTIVES: Atypical lymphatic spread of germ cell tumors to inguinal lymph nodes has been reported mostly related to prior surgical involvement of the inguinoscrotal region, as in orchiopexy. METHODS: A patient with cryptorchidism and failed orchiopexy in his childhood was diagnosed with a testicular neoplasm. Inguinal orchiectomy was performed. RESULTS: Pathological analysis showed classical seminoma spreading into a subcutaneous adjacent lymph node. Further metastatic disease was not found. Patient was treated with adjuvant chemotherapy. CONCLUSIONS: We emphasize the need for accurate staging and a multidisciplinary approach when dealing with onco-urological patients presenting with atypical disease.

Diseminación linfática atípica de un tumor testicular sobre testículo criptorquídico / Atypical lymphatic dissemination of a testicular tumor from a chriptorquid testicle

OBJETIVOS: Existen casos descritos en la literatura de diseminación linfática atípica de un tumor testicular a ganglios inguinales, en la mayoría de las ocasiones asociados a una cirugía previa de la región inguinal o testicular, como es el caso de la orquidopexia en testículos criptorquídicos. MÉTODOS: Presentamos el caso clínico de un paciente con testículo criptorquídico con orquidopexia previa fallida, en el que se diagnostica un tumor testicular y se realiza orquiectomía.RESULTADOS: En el análisis histopatológico se objetiva un tumor de estirpe seminomatosa sobre testículo criptorquídico, así como una diseminación a estación linfática inguinal ipsilateral. El paciente es tratado con quimioterapia complementaria.CONCLUSIONES: Se pretende mostrar la necesidad de establecer una correcta estadificación y el tratamiento más adecuado en los casos con este tipo de afectación linfática(AU)

OBJECTIVES: Atypical lymphatic spread of germ cell tumors to inguinal lymph nodes has been reported mostly related to prior surgical involvement of the inguinos-crotal region, as in orchiopexy.METHODS: A patient with cryptorchidism and failed orchio-pexy in his childhood was diagnosed with a testicular neo-plasm. Inguinal orchiectomy was performed.RESULTS: Pathological analysis showed classical seminoma spreading into a subcutaneous adjacent lymph node. Further metastatic disease was not found. Patient was treated with adjuvant chemotherapy.CONCLUSIONS: We emphasize the need for accurate sta-ging and a multidisciplinary approach when dealing with onco-urological patients presenting with atypical disease(AU)

[Percutaneous treatment of calyceal diverticulum associated with lithiasis]. / Tratamiento percutáneo de divertículo calicial asociado a litiasis.

OBJECTIVES: To report the case of a 47-years-old woman with several small stones located inside a calyceal diverticulum of the right kidney and to highlight the importance of minimally invasive endourological treatment in these cases. METHODS: Owing to the presence of diverticular calculi and clinical symptoms of recurrent infection, we decided to perform percutaneous nephrolithotomy (PNL). After Holmium-YAG laser calculi fragmentation and removal of all stone material, we fulgurated the diverticular lining and infundibulum with a resectoscope and a rollerball electrode. RESULTS: The patient is free of symptoms after 6 months follow-up. The disappearance of the calculi and diverticulum is confirmed with excretory urogram. CONCLUSIONS: Endourological approach for diverticular calculi, such as percutaneous nephrolithotomy (PNL), is a minimally invasive treatment with excellent results and low morbidity. Using this procedure we are able to perform stone removal and cavity fulguration. According to this, we think that endourological techniques, and specially PNL could be the first option for treatment in selected cases of this pathology.

Tratamiento percutáneo de divertículo calicial asociado a litiasis / Percutaneous treatment of stone-containing calyceal

OBJETIVO: Presentar el tratamiento percutáneo del divertículo calicial asociado a litiasis de localización posterior y resaltar la importancia que ha cobrado en los últimos tiempos el tratamiento endourológico, mínimamente invasivo, para este tipo de patología.MÉTODOS: Debido a la presencia de litiasis múltiple intradiverticular y sintomatología infecciosa recurrente asociada, se decide realización de nefrolitotomía percutánea (NLPC). Tras extracción de las litiasis, se procede a la obliteración de infundíbulo calicial mediante electrocoagulación con resector y electrodo “rollerball”.RESULTADOS: La paciente se encuentra libre de sintomatología a los 6 meses de seguimiento. Se confirma desaparición de divertículo calicial y litiasis mediante urografía intravenosa (UIV).CONCLUSIONES: El manejo endourológico de la litiasis alojada en un divertículo calicial de localización posterior mediante nefrolitotomía percutánea es un tratamiento mínimamente invasivo con excelentes resultados y escasa morbilidad. Permite la resolución no sólo de la patología litiásica, sino además la obliteración de la cavidad diverticular. Todo ello confirma que las técnicas endourológicas, y más específicamente la NLPC, son el tratamiento de elección en gran parte de los pacientes con esta patología(AU)

OBJECTIVES: To report the case of a 47 years old woman with several small stones located inside a calyceal diverticulum of the right kidney and to highlight the importance of minimally invasive endourological treatment in these cases.METHODS: Owing to the presence of diverticular calculi and clinical symptoms of recurrent infection, we decided to perform percutaneous nephrolithotomy (PNL). After Holmium-YAG laser calculi fragmentation and removal of all stone material, we fulgurated the diverticular lining and infundibulum with a resectoscope and a rollerball electrode.RESULTS: The patient is free of symptoms after 6 months follow-up. The disappearance of the calculi and diverticulum is confirmed with excretory urogramLun CONCLUSIONS:Endourological approach for diverticular calculi, such as percutaneous nephrolithotomy (PNL), is a minimally invasive treatment with excellent results and low morbidity. Using this procedure we are able to perform stone removal and cavity fulguration. According to this, we think that endourological techniques, and specially PNL could be the first option for treatment in selected cases of this pathology(AU)

Utilidad del laser de holmium: yag en la sección endoscópica de la estenosis ureteral / Usefulness of the holmium: yag laser in the endoscopic section of ureteral stenosis

La incidencia de la estenosis ureteral es frecuente en nuestro medio. En los últimos tiempos, debido al masivo empleo de técnicas endourológicas, ha aumentado su incidencia. Su etiología representa un factor decisivo para el resultado final del tratamiento, pero existen además características comunes a todas las estenosis que influyen de forma muy importante en el éxito final: tiempo de evolución, longitud de la estenosis, localización de la misma y función de la unidad renal afecta. En los últimos años se ha incrementado la utilización de diferentes técnicas endourológicas para el tratamiento de las estenosis del aparato urinario superior, que vienen a sustituir a la técnica abierta tradicional. La endoureterotomía con láser de Holmium:YAG presenta ventajas frente a otras técnicas endourológicas empleadas, ya que permite una incisión precisa con visión directa sobre la estenosis ureteral. Además, con las fibras de láser se cosigue una flexibilidad/deflexión del ureteroscopio, que permite alcanzar, en la inmensa mayoría de los casos, la zona estenótica. A la hora de realizar la incisión sobre la pared ureteral, ésta debe ser completa, actuándose sobre todas las capas del uréter hasta visualizar la grasa periureteral, teniendo siempre en cuenta las relaciones del uréter con las estructuras vecinas, especialmente las vasculares, para evitar lesionarlas. Su efectividad y fácil manejo, permiten obtener una elevada tasa de éxitos, con resolución de la patología estenótica, y una muy baja tasa de complicaciones. Por todo ello, debe incluirse a la endoureterotomía retrógrada con láser de Holmium:YAG en la primera línea del tratamiento de las estenosis ureterales de tipo benigno (AU)

Objectives: The incidence of ureteral stenosis is frequent in our environment. Lately, due to the massive use of endourological techniques its incidence has increased. Etiology represents a decisive factor for the final result of treatment, but there are also common characteristics to all stenosis that influence very importantly the final success: time of evolution, length of the stenosis, side and function of the affected renal unit. Over the last years, the use of endourological techniques for the treatment of upper urinary tract stenosis, that substitute the traditional open technique, have increased. Holmium:YAG laser endoureterotomy presents advantages in comparison with other endourological techniques, because it enables a precise incision with direct vision of the ureteral stenosis. Moreover, with laser fibers ureteroscopes achieve a degree of flexibility/ deflection that enables us to reach in most cases the stenotic area. At the time of incision of the ureteral wall, it should be complete, acting on all ureteral layers down to the periureteral fat, always having in mind the anatomic relationships of the ureter with neighbour structures, mainly vascular, to avoid injuries. Its effectiveness and easy management permits a high success rate, with resolution of the stenosis and a very low complication rate. After all the anterior, holmium laser retrograde endoureterotomy should be included as a first line treatment for benign ureteral stenosis (AU)

Endopielotomía retrógrada con láser / Retrograde laser endopyelotomy

La Estenosis de la Unión Pieloureteral (EUPU) es la anomalía congénita más frecuente del tracto urinario superior. Hasta hace unos años, el tratamiento de primera elección era la pieloplastia abierta, pero el desarrollo de la cirugía endoscópica y la mejora técnica en la instrumentación de la misma, permite su tratamiento de forma minimamente invasiva, ofreciendo las ventajas de un menor tiempo operatorio, una menor morbilidad, disminución de analgesia en el postoperatorio, estancia hospitalaria más corta y un menor periodo de convalecencia. La Endopielotomía Retrógada representa la evolución natural del tratamiento quirúrgico mínimamente invasivo de la EUPU al eliminar la necesidad de un trayecto percutáneo renal y sus posibles complicaciones. Puede ser realizada de tres formas: con ureteroscopio semirrígido e incisión con electrocauterio, corte frío o láser; con ureteroscopio flexible e incisión con electrocauterio o láser; y bajo control de escopia con el catéter balón de corte AcuciseTM. En la actualidad, el desarrollo de ureterorrenoscopios de menor calibre (semirrígidos y flexibles) y el uso de fuentes de energía más seguras y eficaces, como el láser de holmium-YAG, han mejorado los resultados de esta técnica. Se presenta la técnica de realización y una revisión de la literatura (AU)

Ureteropyelic junction obstruction (UPJO) is the most frequent congenital anomaly of the upper urinary tract. Until some years ago, the treatment of first choice was open pyeloplasty, but the development of endoscopic surgery and the clinical improvement on instruments, enables the treatment in a minimally invasive fashion, offering the advantages of shorter operative time, less morbidity, reduction of post operative analgesic requirements, shorter hospital stay, and shorter convalescence period. Retrograde endopyelotomy represents the natural evolution of the minimally invasive surgical treatment of the UPJO by eliminating the need of a percutaneous renal tract and its possible complications. It may be performed in three ways: semirigid ureteroscope and electrocautery, cold knife or laser incision; flexible ureteroscope and electrocautery or laser incision; and under x-ray control with the AcuciseTM cutting balloon catheter. Currently, the development of smaller ureterorenoscopes (semirigid and flexible) and the use of safer and more effective energy sources, such as holmium:YAG laser, have improved the results of this technique. We present the technique step-by-step and a bibliographic review (AU)

Litiasis en cáliz inferior: utilidad del Láser / Lower calyx lithiasis: usefulness of the laser

Todavía permanece en controversia cual es la mejor modalidad de tratamiento para las litiasis localizadas en el cáliz inferior. El rango de aclaramiento litásico de los cálculos situados en el cáliz inferior va a depender de diferentes factores como el tamaño y la composición del cálculo, el tipo de litotriptor utilizado, el tipo de transporte urinario y la anatomía del cáliz inferior. El papel de la Ureteroscopia (URS) flexible en el tratamiento de la patología intrarrenal ha experimentado una dramática evolución, impulsada por las mejoras en el diseño de los ureteroscopios flexibles, en su grado de deflexión y mejora de la calidad de imagen, en la gran diversificación de la intrumentación accesoria de pequeño calibre y en el uso del láser de Holmium (Ho: YAG) para la litotricia. Su desarrollo permite ofrecerla como modalidad terapeútica en los fracasos de la Litotricia Extracorpórea (LEC) en litiasis menores de 1 cm y como primera línea de tratamiento en las litiasis menores de 1 cm en casos de cálculos de cistina y en aquellos con niveles de atenuación mayores a 1000 HU; así como en pacientes obesos o con problemas de coagulación (AU)

There is controversy yet about which is the best treatment modality for lithiasis of the lower calyx. The range of lithiasis clearance of the stones localized in the lower calyx will depend on various factors such as size, composition of the stone, type of lithotripter employed, type of urinary transport, and anatomy of the lower calyx. The role of flexible ureteroscopy in the treatment of intrarenal pathology has experimented a dramatic evolution, impulsed by the improvements in design of flexible ureterscopes, their degree of deflection, and better quality of image, in the great diversification of small calibre accessory instruments, and the use of the holmium laser for lithotripsy. Its development makes possible to offer it as a therapeutic option for the failures of extracorporeal lithotripsy in stones smaller than 1 cm and as first-line treatment for stones smaller than 1 cm in size if they are cystine stones or they have an attenuation level over 1000 HU; also in obese patients or those with coagulation problems (AU)

Dispositivos antimigración durante la litotricia endoscópica con láser de holmium: yag / Antimigration devices during endoscopic lithotripsy with holmium: yag laser

Objetivo: La patología litiásica continúa siendo muy prevalente en nuestro medio. Existen múltiples enfoques y tratamientos para resolverla dentro de la urología actual. En los últimos tiempos, las técnicas endourológicas han sufrido un espectacular avance que ha permitido aumentar su tasa de éxito, disminuyendo también de forma importante su comorbilidad. Sin embargo, a pesar de todas estas mejoras, nos encontramos aún con una serie de complicaciones que pueden reducir el éxito del procedimiento. Entre todas ellas, destacamos la retropulsión de la litiasis que ocurre durante la litofragmentación endoscópica, ya que aparece en un número importante de procedimientos y, no solo ocasiona un descenso del rango de «stone free», sino que además conlleva un alargamiento del tiempo quirúrgico y, en ocasiones, hará necesario el empleo de procedimientos adicionales que aumentarán el coste y la morbilidad del tratamiento. Para reducir la incidencia de esta retropulsión se han empleado maniobras clásicas: antitrendelenburg, disminución de la intensidad de flujo de irrigación, modificación de los parámetros del láser o balones neumáticos. Actualmente disponemos de otros mecanismos más eficaces para combatirla, entre ellos: dispositivos que ocluyen la luz ureteral y cestillas/fórceps de nitinol. La selección adecuada del dispositivo de extracción del cálculo puede ser decisiva para completar con éxito, y en el tiempo programado, un procedimiento ureteroscópico. La elección de un dispositivo inadecuado puede imposibilitar el procedimiento o causar un daño iatrogénico al tracto urinario. Por todo ello, el instrumental específico para atrapar y extraer litiasis (cestillas y dispositivos que ocluyen la luz ureteral) es un armamentarium con el que todo endourólogo debería estar familiarizado (AU)

Objectives: Lithiasic pathology continues being very prevalent in our environment. There are multiple approaches and treatments to solve it in current urology. Lately, endourological techniques have suffered a spectacular advance which has permitted to increase their success rates, diminishing also their comorbidity very much. Nevertheless, despite all improvements we still face a series of complications that may reduce the success of the procedure. Among all of them, we emphasize stone retropulsion during endoscopic lithotripsy, because it appears in an important number of procedures and, it does not only diminish the range of stone free patients, but also is associated with a longer surgical time, and occasionally will make necessary the employment of additional procedures that increase cost and treatment morbidity. To reduce the incidence of this retropulsion classical manoeuvres have been employed: antitrendelenburg, decrease of the intensity of the irrigaton flow, modification of laser parameters, or pneumatic balloons. Currently, we have other more effective mechanisms to combat it, among them: the devices that occlude the ureteral lumen, and nitinol baskets/forceps. Adequate selection of the stone extraction device may be definitive for completion of the ureterorenoscopic procedure with success, and in the programmed time. The election of an inadequate device may make the procedure impossible or cause iatrogenic damage to the urinary tract. For all it, specific instruments to entrap and extract stones (baskets and ureteral lumen occlusion devices) is an armamentarium that every endourologist should be familiar with (AU)

Utilidad del litotriptor Stonebreakertm en la nefrolitotomía percutánea / Usefulness of the StoneBreakertm lithotripter for percutaneous nephrolithotomy

Objetivo: La litiasis de la vía urinaria es una patología de gran prevalencia para cuyo tratamiento se han utilizado diversos dispositivos a lo largo de la historia. El StoneBreakerTM (LMA Urology, Gland, Switzerland) pertenece a una segunda generación de litotriptores intracorpóreos, neumático y portátil, que aporta algunas ventajas respecto a otros dispositivos, tanto por su eficacia en la fragmentación de las litiasis como por su fácil manejo, muy útiles durante la realización de la nefrolitotomía percutánea. Métodos/Resultados: Presentamos el caso de un varón de 40 años con litiasis piélica de riñón izquierdo, al que se realiza nefrolitotomía percutánea bajo anestesia general, usando como litotriptor para la fragmentación de la misma el StoneBreakerTM (LMA Urology, Gland, Switzerland). Conclusión: El StoneBreakerTM (LMA Urology, Gland, Switzerland) es un litotriptor para uso con endoscopios rígidos o semirrígidos, con mayor poder de fragmentación que sus antecesores, que consigue disminuir el número de disparos necesarios para la fragmentación de las litiasis, sin que esto repercuta en un aumento del daño tisular. Además también ha sido diseñado con una mayor comodidad de uso, gracias a que no precisa de conexiones y se acciona por medio de cartuchos desmontables de dióxido de carbono (AU)

Objective: Throughout the history, many devices have been used for breaking urinary tract stones. StoneBreakerTM (LMA Urology, Gland, Switzerland) is a second generation of intracorporeal lithotripter, pneumatic and portable, which adds several new advantages, like effectiveness in stone fragmentation and easy handling, very useful during percutaneous lithotripsy. Methods/Results: We report the case of a 40 year-old male patient, with a left kidney pyelic lithiasis, who was treated by percutaneous lithotripsy, under general anaesthesia, with StoneBreakerTM (LMA Urology, Gland, Switzerland) as lithotripter. Conclusions: StoneBreakerTM (LMA Urology, Gland, Switzerland) is a lithotripter usable with rigid and semirigid ureteroscopes, much more powerful than its predecessors. It is able to decrease the number of shocks necessary for stone fragmentation, without bigger tissue reaction. It also has a more comfortable design due to the absence of connections, and its power by replaceable carbon dioxide cartridges (AU)

[Usefulness of the holmium:yag laser in the endoscopic section of ureteral stenosis]. / Utilidad del láser de holmium:yag en la sección endoscópica de la estenosis ureteral.

OBJECTIVES: The incidence of ureteral stenosis is frequent in our environment. Lately, due to the massive use of endourological techniques its incidence has increased. Etiology represents a decisive factor for the final result of treatment, but there are also common characteristics to all stenosis that influence very importantly the final success: time of evolution, length of the stenosis, side and function of the affected renal unit. Over the last years, the use of endourological techniques for the treatment of upper urinary tract stenosis, that substitute the traditional open technique, have increased. Holmium:YAG laser endoureterotomy presents advantages in comparison with other endourological techniques, because it enables a precise incision with direct vision of the ureteral stenosis. Moreover, with laser fibers ureteroscopes achieve a degree of flexibility/deflection that enables us to reach in most cases the stenotic area. At the time of incision of the ureteral wall, it should be complete, acting on all ureteral layers down to the periureteral fat, always having in mind the anatomic relationships of the ureter with neighbour structures, mainly vascular, to avoid injuries. Its effectiveness and easy management permits a high success rate, with resolution of the stenosis and a very low complication rate. After all the anterior, holmium laser retrograde endoureterotomy should be included as a first line treatment for benign ureteral stenosis.

[Retrograde laser endopyelotomy]. / Endopielotomía retrógrada con láser.

Ureteropyelic junction obstruction (UPJO) is the most frequent congenital anomaly of the upper urinary tract. Until some years ago, the treatment of first choice was open pyeloplasty, but the development of endoscopic surgery and the clinical improvement on instruments, enables the treatment in a minimally invasive fashion, offering the advantages of shorter operative time, less morbidity, reduction of post operative analgesic requirements, shorter hospital stay, and shorter convalescence period. Retrograde endopyelotomy represents the natural evolution of the minimally invasive surgical treatment of the UPJO by eliminating the need of a percutaneous renal tract and its possible complications. It may be performed in three ways: semirigid ureteroscope and electrocautery, cold knife or laser incision; flexible ureteroscope and electrocautery or laser incision; and under x-ray control with the Acucise cutting balloon catheter. Currently, the development of smaller ureterorenoscopes (semirigid and flexible) and the use of safer and more effective energy sources, such as holmium:YAG laser, have improved the results of this technique. We present the technique step-by-step and a bibliographic review.

[Lower calyx lithiasis: usefulness of the laser]. / Litiasis en cáliz inferior: utilidad del láser.

There is controversy yet about which is the best treatment modality for lithiasis of the lower calyx. The range of lithiasis clearance of the stones localized in the lower calyx will depend on various factors such as size, composition of the stone, type of lithotripter employed, type of urinary transport, and anatomy of the lower calyx. The role of flexible ureteroscopy in the treatment of intrarenal pathology has experimented a dramatic evolution, impulsed by the improvements in design of flexible ureterscopes, their degree of deflection, and better quality of image, in the great diversification of small calibre accessory instruments, and the use of the holmium laser for lithotripsy. Its development makes possible to offer it as a therapeutic option for the failures of extracorporeal lithotripsy in stones smaller than 1 cm and as first-line treatment for stones smaller than 1 cm in size if they are cystine stones or they have an attenuation level over 1000 HU; also in obese patients or those with coagulation problems.

[Antimigration devices during endoscopic lithotripsy with holmium: yag laser]. / Dispositivos antimigración durante la litotricia endoscópica con láser de holmium:yag.

OBJECTIVES: Lithiasic pathology continues being very prevalent in our environment. There are multiple approaches and treatments to solve it in current urology. Lately, endourological techniques have suffered a spectacular advance which has permitted to increase their success rates, diminishing also their comorbidity very much. Nevertheless, despite all improvements we still face a series of complications that may reduce the success of the procedure. Among all of them, we emphasize stone retropulsion during endoscopic lithotripsy, because it appears in an important number of procedures and, it does not only diminish the range of stone free patients, but also is associated with a longer surgical time, and occasionally will make necessary the employment of additional procedures that increase cost and treatment morbidity. To reduce the incidence of this retropulsion classical manoeuvres have been employed: antitrendelenburg, decrease of the intensity of the irrigaton flow, modification of laser parameters, or pneumatic balloons. Currently, we have other more effective mechanisms to combat it, among them: the devices that occlude the ureteral lumen, and nitinol baskets/forceps. Adequate selection of the stone extraction device may be definitive for completion of the ureterorenoscopic procedure with success, and in the programmed time. The election of an inadequate device may make the procedure impossible or cause iatrogenic damage to the urinary tract. For all it, specific instruments to entrap and extract stones (baskets and ureteral lumen occlusion devices) is an armamentarium that every endourologist should be familiar with.